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substance abuse treatment
"The now tenacious attachment of the disease model and 12-step philosophy to caring behavior, commonly known as codependency, represents to me the most confusing and iatrogenic ideas in the realm of clinical psychology." ----Robert Westermeyer, Ph.D.
Self-help is an enterprise wherein people holding the thinnest of credentials diagnose in basically normal people symptoms of inflated or invented maladies, so that they may then implement remedies that have never been shown to work. --Steve Salerno
Substance abuse treatment is a behavior modification therapy for those who use drugs or alcohol to the detriment of themselves and others.
Law enforcement officials, politicians, and religious leaders often cite drug and alcohol abuse as evils so great that they threaten the survival of our society. Countless individuals worry constantly about their own and others' drinking or drug behaviors. Waiting to help all those with substance abuse "problems" are thousands of professionals in the "helping" professions. But are they really helping substance abusers? Or is substance abuse treatment (SAT) a racket designed primarily to make money or to promote some other selfish goal, with little regard for the health or well-being of patients? Or is SAT a mixture of good and evil, much like the people it avers to help? Is there scientific evidence that any of these SAT programs work better than trying to sober up on one's own?
What one can't deny is that many people swear by A.A. and other SAT programs. As one correspondent put it: "A.A. changed my life. I couldn’t have turned my life around on my own. I might be dead without it. I would certainly be in a great deal of physical, mental, and emotional trouble." I know that many people get sober and turn their lives around after some sort of SAT. I know also that for every success story there are many more stories of failure. I don't want to discourage anyone from trying SAT programs, any more than I would want to discourage an obese person from trying another dieting program. At some point in any one of a myriad of processes some people make the change from an unhealthy lifestyle to a healthy lifestyle. What's the harm if they attribute their success to A.A. or WeightWatchers rather than to their own resolve? But it should be noted that there is not much credible evidence that SAT programs will help most people trying to get sober. The reason nobody knows why some SAT programs work for some people and not for others may be that the success stories have little to do with the SAT programs themselves.
the road to Hell is paved with good intentions
Criticizing those who profess to help substance abusers is unlikely to be welcomed either by those who see substance abuse as a subversive activity or by those who believe their own lives or the lives of loved ones have been or are now being destroyed by drugs or alcohol. The psychologists, psychiatrists, interventionists, and aides who work in treatment facilities are unlikely to welcome criticism. Likewise for the owners and managers of such places. Nevertheless, it is unconscionable to allow an industry to go unchecked simply because they claim to have good intentions.
Charles Dederich (1913-1997), who created Synanon, had good intentions. He would help drug addicts. In a little over twenty years, from 1958 to 1980, Synanon grew to an authoritarian cult with perhaps between $30 million and $50 million in assets. Instead of saving families, Synanon destroyed them. Of the 6,000 to 10,000 residents of Synanon between 1958 and 1968, only 65 people were rehabilitated, i.e., reached Synanon's stated goal of choosing to live and work outside of the Synanon community (Ofsche 1980, 110). Dederich's empire collapsed when he pleaded no contest to a charge of conspiracy to commit murder. How do the Dederichs of the world get away with it? In his case, he was doing society's dirty business of helping drug addicts. To attack a person or an organization that is helping people is to show bad form and will generally be unrewarded. Furthermore, we all want such endeavors to succeed and are more apt to seek out confirmation of their successes than to criticize their failures. Programs like Synanon are the darlings of the media—and politicians in election years—until their warts become too obvious to ignore. Unfortunately, these natural tendencies give the unscrupulous carte blanche to abuse the rest of us.
The goals of SAT may be noble, but that does not justify using any means necessary to achieve those goals. To allow treatment that denies a person his or her human as well as civil rights should not be tolerated. To treat people for questionable diseases should not be tolerated. To use therapeutic techniques with little or no substantive evidence for their effectiveness should not be tolerated. While there are many SAT programs that respect the basic humanity of their patients and do a good and decent job of helping substance abusers, there are also programs that are not being monitored carefully by anyone, thus inviting abuse.
Interventions are commonly used on those thought to be substance abusers by concerned relatives and friends. The element of surprise is often used in these interventions. Several people, including in some cases a professional interventionist, confront the subject who is immediately on the defensive; not that it much matters, for any defense is taken as "being in denial." The shock of the intervention, its humiliating aspects, the intimidation of numbers, all combine to prevent any sort of rational exploration of the situation. This is of little importance, since the intervention is to be an emotional experience, not an intellectual one. The subject must feel (a) how much he or she is loved and (b) how substance abuse is ruining their lives. Presumably, at an intellectual level, the abuser already knows these things, but the value of this knowledge has no effect on their behavior.
The interventionist is a paid professional. He or she is paid not for caring for the person admitted but for getting the person admitted. The interventionist takes on the role of Grand Inquisitor and deliverer, rather than that of counselor. But what justifies such a position? Why are there interventionists at all? They’re needed to assist families in convincing a loved one to seek treatment. They are there to offer professional support to those who want their loved one treated. But why do people need an outsider, a stranger, to help convince their loved one to seek treatment? Is it because the interventionist plays the role of the independent facilitator, a disinterested professional? If so, then the position is a fraud. For the interventionist is not independent or disinterested, but is (a) primed to believe the subject is an abuser and (b) paid for delivery of a live customer to the treatment facility.
Should the subject agree to enter a treatment facility for alcohol abuse, he is also entering a world of ideas, the main one being that alcohol abuse is a disease whose main symptom is a weak will. The main manifestation of this weak will is an inability to drink moderately, thus requiring total abstinence from alcohol as the only way to control the disease. Many subjects will be required to join a group such as Alcoholics Anonymous, where they will also enter a world of ideas known as the 12-step program where they will be assisted in the treatment of their disease. Unlike other diseases, this one is treated as a character flaw that can't be eliminated, but can be controlled by abstaining from all alcoholic beverages.
There are some A.A. programs that give the nod to the "genetic disease" model of alcoholism.* Those familiar with A.A. will recognize that the "disease" model of substance abuse contradicts the A.A. model of the weak-willed sinner who needs a "Higher Power" (which can mean anything from the A.A. group itself to the god of the Bible) to conquer the mighty forces of satanic booze. These clashing metaphors of the victim and the sinner are contradictory: the one makes the victim passive and not responsible for being an abuser; the other puts the burden of responsibility on the alcoholic. The burden is mitigated by seeking help from a "higher power," which some identify with a god but which can mean just about anything outside of the self. Several A.A. members who I know, and others who have contacted me by email, claim that there has been no religious ideas forced on anyone in their meetings. If the participant appeals to a god, that's his or her prerogative, but others are free to ignore such appeals. One friend of mine considers the A.A. group itself to be his "higher power."
The disease model of alcoholism
What are the signs of this disease? In addition to craving drink and an inability to stop drinking after one or two drinks, one symptom of this disease is quantity of alcohol consumed. An alcoholic may require rather large amounts of drink before he or she feels a buzz much less feels drunk. If you drink no more than the average American adult, then you probably do not have this disease. If you drink more than that, then you are probably an alcoholic. The National Institute on Alcohol Abuse and Alcoholism defines a moderate drinker as someone who drinks an average of 3 to 14 drinks a week. A heavy drinker has an average of more than two drinks a day. A drink is 12 ounces of beer, one glass of wine or one shot of liquor. (In case you are wondering, if you drink 3 or more drinks a week you are in the minority: only 27% have that many drinks.)
Another symptom of this disease is when you drink. If you drink when stressed or depressed, lonely or bored, to get motivated or amorous, to test yourself or to feel good, then you are very likely an alcoholic. A better sign, however, is suffering from withdrawal symptoms. If you get nauseous, the cold sweats or the shakes when you don't drink, you are without doubt an alcoholic.
One of the unique features of this disease is that the effects of the disease are usually first felt by people other than the one suffering from the disease. For most diseases, the sick person feels bad. If the sick person doesn’t feel bad, nobody else feels bad. If alcoholism is a disease, it must be a mental illness. The mentally ill often deny they are ill and the first identification of a mental illness is often when others notice that the afflicted person is behaving in unconventional, bizarre or self-destructive ways. Like other mental illnesses, there is no blood or urine test for alcoholism. There is no physical marker the healer can look for to identify the disease. All the signs are behavioral.
Unlike mental illness, however, alcohol abuse is self-inflicted and might better be called brain abuse (in addition to liver abuse).
One cynical view of the matter is that alcoholism as a disease is not a matter of discovery, but of definition. It is a disease because it has been declared to be so by the very ones who profess to have the cure for the disease. How fortunate for the world that those who define the disease also define the cure! Actually, they don’t have a "cure." They have a remedy. The inventors of the disease also declare that no one can be cured of this disease. Once an alcoholic, always an alcoholic. You haven’t had a drink in fifty years, you say. That is not evidence that you are no longer an alcoholic. A cure would mean an end to treatment. A remedy means a lifelong income for the SAT provider.
The treatment usually begins by being repeatedly told that the first step to recovery is the declaration: I am an alcoholic. For the sinner to be saved, the sinner must first admit he is a sinner. (I am not claiming that A.A. uses the word 'sin' or 'sinner' or 'grace' or that there is any official use of theological terminology. As noted above, even the reference to "a higher power" may only in some instances be taken to have a religious connotation.) To refuse to do so is proof the sick one is "in denial" and without grace. The only way to prove you are not in denial is to admit you are an alcoholic. This is only phase one. The next phase is public confession: the subject must declare before others how they have degraded themselves and betrayed their humanity through substance abuse. Confession is good for the soul, they say, and I suppose the point of declaring the harm one has done to oneself and others is a form of self-cleansing. The practice of apologizing to those you've hurt, however, can have unforeseen and horrendous consequences.
Neither A.A. nor many other SATs are based on science, nor do they seem interested in doing any scientific studies that might test whether the treatment they give is effective. A.A. members know A.A. works, so they don’t need studies to verify the effectiveness of the program. They have very vivid testimonials from people like Bill Wilson, the founder of A.A., of hopeless alcoholics whose only salvation was a religious experience. But others might like to know how many don’t stay and go through the program? How many go through it, but leave? We only hear about the successes, not the failures, because the failures aren’t counted; they aren’t around to be counted. We won’t read about any comparisons with non-A.A. programs, nor will we hear about those substance abusers who quit drinking or drugs without any treatment at all. They didn’t need a "higher power" or the group’s help to quit; they did it on their own. How is that possible? If alcoholism is a disease for which there is no cure how do some people quit abusing alcohol or drugs on their own? This should not be possible if either the A.A. philosophy or the disease theory is correct.
We know that many studies have found that many people who abuse alcohol have stopped the abuse on their own. The studies vary in quality and the results are wildly disparate, but most of them found at least 40% success rates with no treatment at all. Getting data from A.A. is not easy, but their own people say that they have a success rate of about 40% (Salerno 2005: 142). The probability is that the success rate is much lower. I say this because AA doesn't keep records of those who quit the program.
Even if alcoholism is a sin and a matter of self-control, it is especially foolish to treat all alcoholics with the A.A. 12-step program. All alcoholics don’t come from the same mold. They are not all physically addicted. They are not all psychologically addicted. They are not all addicted. They are not all victims. They are not all diseased. They are not all hopelessly without any self-control. They are not all completely irrational and incompetent. They are not all mentally ill. They don’t all need therapy or medication. There are probably many good programs besides those based on the "disease" or the "sinner" models of the alcoholic. Substance abusers who want to get back some control in their lives might check out some of these other programs and not feel it’s either A.A. or a "chemical dependency" program or nothing.
One final note: it seems rather curious that Bill Wilson, founder of A.A., credited people like Carl Jung and William James’s Varieties of Religious Experience for helping him see that "ego collapse" is the common denominator in conversion experiences and that such an experience was the one the alcoholic must have in order to reform. (Wilson also wrote fondly to Jung that some in A.A. had become devotees of psychic powers and the I Ching, a favorite of Jung’s.) Jung had simply thought that some people were hopeless and therapy could do them no good, but perhaps religious devotion could help them. James catalogued experiences as part of his pragmatism: the truth of religion is in its fruits, its effects on a person’s life. The idea is attractive if you keep one eye shut and ignore the Jim Joneses, Jerry Falwells, David Koreshes, Peter Popovs, and Pat Robertsons of the world. The idea might seem true to someone whose selective memory ignores all the alcoholic priests, priestesses, and devoted churchgoers.
I'll conclude with a formal testimonial given to me by a very good friend who has been sober, thanks to A.A., for more than five years after at least 25 years of abuse of alcohol and a number of legal and illegal substances:
My name is ____________ and I'm an atheist.
I am addressing this to the alcoholics who have had trouble with the religious overtones in the A.A. program. To those who do not accept the idea of a supernatural being, let me assert that it is always people who have strengthened me when I needed help.
I have a deep belief in human morality. I believe that evil impulses can be subordinated by decent actions. A.A. brings out impulses for good, and this has tremendous force. In my opinion, this sum total of good actions is the "higher power."
In the words of a Unitarian minister: "In a world that has lost, or is losing fast, any convincing concept of divine providence at work, of a personal god ordering the affairs of humanity, it is not necessary to assume that the only alternative to a human-cherishing universe is a hostile or satanic universe. There is the much more likely alternative of a neutral universe where people live, hammering out salvation without hope of heaven or dread of hell. People can find that life has value, not because a divine being so ordains, but because the achievements of good men and women, laboring together with love and self-respect, are self-validating and self-rewarding."
I was not able to accept A.A. or the very real help it could give until I made a rationalistic interpretation of the program. I am still an atheist, but I am a grateful atheist.
I don't want to change A.A. It works for me. I just want it to be effective in attracting rationalists. Their membership will help A.A. tremendously.
To which I say, amen brother, as I note that there are alternatives such as Rational Recovery or SOS. Or, if you don't buy the notion that every abuser of alcohol is an alcoholic for life, you might be able to go it alone or with the help of a loving partner. Maybe some people must totally abstain from alcohol to avoid chaos and destruction in their lives. Others have gone from abuse to moderation. The evidence isn't there to support the claim that every substance abuser is an abuser for life and can only avoid the destruction abuse brings by total abstinence.
See also codependency.
books and articles
Ofshe, Richard. (1980). "The Social Development of the Synanon Cult: The Managerial Strategy of Organizational Transformation," Sociological Analysis 41: 109-127.
Stinkin' Thinkin' Stinkin’ Thinkin’ was started with the intention of highlighting the quackery and abuse that is the foundation of the addictions treatment industry – with a view toward building community among people who are questioning the only game in town....We do not want to destroy Alcoholics Anonymous. We don’t want to remove it as an option for the people who choose it and like it. It should always be a choice.We want to see it occupy a more appropriate niche in our society; to be honest and realistic about what it is and what it can and cannot offer people.
Can You Cure Yourself of Drug Addiction? "A prevailing view of substance abuse, supported by both the National Institute on Drug Abuse and Alcoholics Anonymous, is the disease model of addiction. The model attributes addiction largely to changes in brain structure and function. Because these changes make it much harder for the addict to control substance use, health experts recommend professional treatment and complete abstinence. But some in the field point out that many if not most addicts successfully recover without professional help."
Even so, there are some people who owe their lives to AA and 12-step programs. Go figure.
Secret of AA: After 75 Years, We Don’t Know How It Works by Brendan I. Koerner "One thing is certain, though: AA doesn’t work for everybody. In fact, it doesn’t work for the vast majority of people who try it. And understanding more about who it does help, and why, is likely our best shot at finally developing a system that improves on Wilson’s amateur scheme for living without the bottle."
In the end, it's just one drunk talking to another Exercise, acupuncture, self-help books, special diets, psychiatrists — nothing worked till he tried Alcoholics Anonymous.
"As Alcoholics Anonymous prepares to celebrate its 75th anniversary, we [Los Angeles Times] asked one of its members to write about the group and how he came to join. Following in the tradition of the organization, he is using his first name only.
My name is Chas. I'm an alcoholic."
An Alcoholic’s Savior: god, Belladonna or Both? Were Bill Wilson’s spiritual awakening and influential sobriety the products of a belladonna hallucination shortly after his discussions with his friend Ebby Thacher? Could they have been incited by his alcohol withdrawal symptoms? Or did something else happen to him that science cannot explain?